GUIDELINE

The role of in gastroduodenal obstruction and

This is one of a series of statements discussing the use of This document describes the role of endoscopy in known GI endoscopy in common clinical situations. The Stan- and suspected obstruction of the proximal GI tract. A dards of Practice Committee of the American Society for discussion of special considerations in a pediatric popu- Gastrointestinal Endoscopy (ASGE) prepared this text. In lation is also included. preparing this guideline, a search of the medical literature was performed by using PubMed. Additional references were obtained from the bibliographies of the identified ETIOLOGY AND PRESENTATION articles and from recommendations of expert consultants. Gastric outlet obstruction (GOO) is caused by mechan- Guidelines for appropriate use of endoscopy are based on ical gastroduodenal obstruction or motility disorders and a critical review of the available data and expert consen- can be divided into 3 major categories: benign mechanical, sus at the time the guidelines are drafted. Further con- malignant mechanical, and motility disorders (Table 2). trolled clinical studies may be needed to clarify aspects of with or without secondary stricture is this guideline. This guideline may be revised as necessary the most common cause of benign mechanical GOO, to account for changes in technology, new data, or other although the recent decline in peptic ulcer disease has aspects of clinical practice. The recommendations are decreased the incidence of clinically evident peptic stric- based on reviewed studies and are graded on the strength tures.2 Malignant mechanical GOO usually results from of the supporting evidence (Table 1).1 The strength of cancer affecting the distal or proximal duode- individual recommendations is based both on the ag- num. Gastric and pancreatic cancers are the most common gregate evidence quality and an assessment of the an- malignant mechanical causes of GOO.3 ticipated benefits and harms. Weaker recommendations The most common gastric motility disorder is gastro- are indicated by phrases such as “We suggest ...,” paresis, often resulting from long-standing diabetes, al- whereas stronger recommendations are typically stated though gastroparesis may also be idiopathic, viral, or as “We recommended ...” related to medications.4-6 Surgical procedures that inten- This guideline is intended to be an educational device tionally or unintentionally disrupt the vagus nerve (eg, to provide information that may assist endoscopists in procedures for peptic ulcer disease, bariatric procedures, providing care to patients. This guideline is not a rule and esophagectomy, fundoplication) may also result in gastro- should not be construed as establishing a legal standard of paresis. Several solid and hematologic may care or as encouraging, advocating, requiring, or discour- induce gastroparesis and small-bowel dysmotility through aging any particular treatment. Clinical decisions in any a paraneoplastic process or secondary infiltrative diseases particular case involve a complex analysis of the patient’s (eg, amyloidosis, carcinomatosis).7,8 condition and available courses of action. Therefore, clin- Patients with GOO may present with and vom- ical considerations may lead an endoscopist to take a iting, weight loss, abdominal , early satiety, and/or course of action that varies from these guidelines. abdominal discomfort. Because of shared clinical features, Enteral obstruction and delayed gastric emptying can it is often difficult to distinguish motility disorders from result from a variety of benign and malignant conditions. mechanical obstruction or functional dyspepsia based 9,10 Endoscopy is an important tool in the evaluation of these solely on symptoms. Nevertheless, initial evaluation patients and can identify, localize, or exclude structural should include a detailed history and careful physical causes. Moreover, various endoscopic procedures may be examination. soon after a meal suggests an up- used to treat the underlying etiology or alleviate symptoms. per anatomic abnormality, whereas symptoms delayed for several hours after meals characterize gastroparesis or a more distal obstruction.11 Vomiting will frequently relieve symptoms from a proximal obstructive cause. GOO may not be clinically evident until high-grade obstruction occurs be- cause of the ability of the stomach to distend significantly to Copyright © 2011 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 accommodate contents. Patients with GOO may demonstrate doi:10.1016/j.gie.2010.12.003 a succussion splash on physical examination. www.giejournal.org Volume 74, No. 1 : 2011 GASTROINTESTINAL ENDOSCOPY 13 The role of endoscopy in gastroduodenal obstruction and gastroparesis

Table 1. GRADE System for rating the quality of evidence for guidelines

Quality of evidence Definition Symbol High quality Further research is very unlikely to change our confidence in the estimate of effect QQQQ

Moderate quality Further research is likely to have an important impact on our confidence in the QQQΠestimate of effect and may change the estimate

Low quality Further research is very likely to have an important impact on our confidence in QQŒŒ the estimate of effect and is likely to change the estimate

Very low quality Any estimate of effect is very uncertain QŒŒŒ

Adapted from Guyatt et al.1

Table 2. of gastric outlet obstruction

Mechanical Motility disorders Benign

Peptic ulcer disease Gastroparesis

Crohn’s disease Postsurgical gastroparesis

NSAID-related stricture Medication-associated dysmotility

Anastomotic stricture Systemic disease-associated (eg, scleroderma, amyloidosis)

Postradiation stricture Intestinal pseudo-obstruction

Foreign body or bezoar Paraneoplastic syndrome

Gallstone (Bouveret syndrome)

Benign polyps (eg, antral polyps, inflammatory, hyperplastic, inflammatory pseudotumor, hamartoma, Peutz-Jeghers syndrome)

Eosinophilic

Extrinsic compression (eg, annular pancreas, chronic with/without pseudocyst)

Malignant

Gastroduodenal cancer, gastric lymphoma (eg, MALT lymphoma), pancreatic cancer, cystic of the pancreas, gallbladder and cancer, carcinoid, retroperitoneal lymphadenopathy (eg, metastatic tumor, lymphoma), retroperitoneal sarcoma, leiomyosarcoma, GI stromal tumor

Children

Hypertrophic pyloric , duodenal or pyloric atresia, antral and duodenal webs, gastroduodenal duplication, gastroduodenal intussusception and gastric , heterotopic pancreatic tissue in the gastric antrum, diaphragmatic herniation, malrotation and peritoneal fibrous bands, congenital anomalies of the pancreatobiliary system, , peptic ulcer disease, eosinophilic GI disease, chronic granulomatous disease, Crohn’s disease, lymphoproliferative disease

MALT, Mucosa-associated lymphoid tissue; NSAID, nonsteroidal anti-inflammatory drug.

EVALUATION before endoscopy. CT is the preferred radiologic test for suspected intestinal obstruction.12-14 Because oral barium Most patients with signs or symptoms of gastroduode- contrast may interfere with subsequent endoscopy, its use nal obstruction or dysmotility will require structural eval- should be minimized or avoided if endoscopy is antici- uation with EGD and/or radiographic studies. If complete pated. Furthermore, high osmolar water-soluble contrast intestinal obstruction or perforation is suspected, initial agents can cause severe bronchial irritation and pulmo- evaluation with radiographic studies should be performed nary edema when inadvertently aspirated in the setting of

14 GASTROINTESTINAL ENDOSCOPY Volume 74, No. 1 : 2011 www.giejournal.org The role of endoscopy in gastroduodenal obstruction and gastroparesis obstruction and thus should be used with extreme cau- trostomy with or without feeding tube placement. tion.15 Endoscopic examination after gastric decompres- is the preferred strategy for those patients who are poten- sion can usually identify the nature and the precise level of tial candidates for curative resection. Diagnostic laparos- obstruction, but the degree of the stenosis often does not copy or exploratory may be beneficial to as- correlate with symptoms. Endoscopy also offers the capa- sess the extent of disease with intent to perform surgical bility of tissue sampling and endoscopic therapy, where bypass as deemed necessary. Endoscopic placement of an indicated. SEMS should be considered provided there is no evidence When structural abnormalities have been excluded, GI of obstruction distal to the site of planned deploy- motility can be evaluated by using scintigraphy, radio- ment. In patients with multiple sites of obstruction, palli- graphic contrast techniques, breath testing, electrogastrog- ative decompressive gastrostomy can be considered with raphy, or gastroduodenal manometry. A comprehensive jejunal feeding tube placement or total technical review of the diagnosis of gastroparesis was (TPN). published in 2004.16 Gastroduodenal manometry can be Endoscopic SEMS placement. SEMS are composed of performed to differentiate intestinal myopathy from en- metal alloys designed to be constrainable on a delivery teric or extrinsic neuropathy, but the availability of this test , yet resume their desired shape once the con- 17-19 is limited and may not influence therapy. A wireless straint is removed. Although some can be delivered pH and motility capsule has been developed that can through the endoscope, others have a larger delivery sys- 20,21 assist with assessing GI motility, although its clinical tem that requires placement alongside the endoscope 22 utility remains to be defined. and/or with fluoroscopic guidance. Some SEMSs are cov- ered by a membrane to help prevent tumor ingrowth. A TREATMENT detailed discussion of enteral is available in another ASGE document.35 Benign mechanical obstruction Technical and clinical success of endoscopically Treatment options for benign mechanical obstruction placed SEMSs. Technical success is defined as the suc- include balloon dilation, self-expandable metal stent cessful deployment of the stent at the desired anatomic (SEMS) placement, and surgery. GOO related to peptic location, whereas relief of obstructive symptoms and/or 23-26 ulcer disease can be treated with balloon dilation. improvement of oral intake define clinical effectiveness. Although technical success with immediate symptom im- Attempts to place an SEMS may fail because of the inability provement is common, multiple dilations are often re- to pass the guidewire beyond the level of the obstruction quired.23 Perforation rates with balloon dilation in benign or other anatomic difficulties. Clinical improvement is peptic strictures range from 3% to 7%, with higher rates commonly assessed by the Gastric Outlet Obstruction corresponding to larger balloon diameter of more than 15 Score,36 quality of life, and performance status.37 mm.23,24,27,28 Balloon dilation can also be effective in the Case series of SEMS placement for gastroduodenal ob- treatment of caustic-induced GOO or post-endoscopic struction have found high technical and clinical success submucosal dissection stricture at the .29,30 rates in patients with malignant GOO.3,38-45 It is important Once adequate dilation is achieved, a durable response to note that such studies are often composed of heteroge- is seen in 70% to 80% of patients.23-25 Treatment of Heli- neous patient populations with various malignancies cobacter pylori, when present, elimination of nonsteroidal treated with an assortment of stents, making uniform con- anti-inflammatory drugs, and concurrent use of antisecre- tory therapy may improve sustained response.31 The effi- clusions about efficacy difficult. A systematic review of 32 cacy of proton pump inhibitor therapy may be attenuated case series summarized the technical success and clinical 3 in the setting of GOO because of a failure to reach the effectiveness of SEMSs. The mean survival time was 12 for absorption and premature activation in the weeks (range 1-184 weeks). The technical success rate of 3 acidic environment of stomach.31 Recurrent stricture after endoscopic placement of SEMSs was 97% and ranged 38-45 endoscopic dilation may require surgical treatment. In one from 91% to 100% in prospective studies. Clinical suc- 3,38-45 study, the need for more than 2 endoscopic dilations for cess was 89% overall, ranging from 63% to 95%. Such symptoms was a significant predictor for the need for discrepancies between technical success and clinical suc- surgical treatment.32 Although there have been case re- cess are seen uniformly across prospective studies and ports of SEMS placement for the treatment of benign ste- may be attributed to underlying GI dysmotility with or nosis of the pylorus, the experience with these devices in without neural involvement by tumor, distal obstruction this patient population is very limited.26,33,34 secondary to peritoneal carcinomatosis, or general de- conditioning and anorexia caused by advanced malig- Malignant mechanical obstruction nancy.38,39,46 In the systematic review, the mean time to General considerations. Treatment options for ma- resuming oral intake after SEMS placement was 4 days, lignant GOO include surgical resection, surgical bypass, and 48% were able to resume a full diet, 39% were toler- endoscopic stenting, and palliative decompressive gas- ating soft solids, and 13% were on liquids only.3 Therefore, www.giejournal.org Volume 74, No. 1 : 2011 GASTROINTESTINAL ENDOSCOPY 15 The role of endoscopy in gastroduodenal obstruction and gastroparesis

Approach to the patient with combined enteral Table 3. Adverse events of endoscopically placed self- and biliary obstructions. Patients with malignant gas- expandable metal stents troduodenal obstruction commonly present with or expe- Bleeding rience the development of coincident biliary obstruction. In a systematic review of 243 patients, 61% of patients Perforation receiving a duodenal stent also required a biliary stent.3 Biliary stent placement was performed before duodenal stenting in 41% or at the time of duodenal stenting in 18%, with an additional 2% undergoing stenting afterward. In Aspiration most cases, duodenal stents do not appear to obstruct bile flow even when covered stents bridging the ampulla are used.48 Although successful deployment of biliary stents Biliary obstruction through the interstices of the duodenal stent has been Pancreatitis reported,49,50 this approach is technically more difficult, Cholangitis and in most cases percutaneous, transhepatic placement is needed. For this reason, biliary SEMSs (not plastic stents) Stent migration should be considered before duodenal SEMSs in patients Stent dysfunction with known or impending biliary obstruction and GOO. Percutaneous decompressive gastrostomy. In poor Tumor ingrowth surgical and SEMS candidates with malignant gastroduo- Tumor overgrowth denal obstruction, peritoneal carcinomatosis, and/or dif- Food impaction fuse bowel strictures caused by metastatic lesions, decom- pressive gastrostomy either by percutaneous endoscopic gastrostomy (PEG) or percutaneous radiologic gastros- tomy (PRG) methods may be beneficial. PEG with jejunal patients undergoing SEMS placement need to be informed extension allows decompression in addition to access for of likely limitations on oral intake, including the avoidance enteral nutrition.51 Decompressive PEG or PRG was re- of foods that may result in stent occlusion. In addition, ported to be of significant clinical benefit with high rates of although SEMS placement may significantly improve ob- symptom relief (approximately 90%) and avoidance of structive symptoms, improvement in quality of life and nasogastric tube decompression.52,53 In a study of 370 performance status is not consistently demonstrated in this patients, PRG was reported to have a higher 30-day com- patient population.41-43,47 plication rate than PEG (23% vs 11%, P ϭ .038), including Contraindications and complications of enteral infections and inadvertent tube removal.54 Ascites is SEMSs. Contraindications to SEMS placement include considered a relative contraindication to percutaneous those conditions that generally preclude endoscopic pro- gastrostomy placement.55 However, paracentesis before cedures (eg, severe cardiopulmonary disease, perforated gastrostomy placement may facilitate the successful place- viscus). ment of PRG with low rates.56,57 Complications of enteral stents are listed in Table 3 and Comparative studies of endoscopic and surgical include severe complications (eg, perforation and bleed- palliation of malignant GOO. The optimal modality for ing) in approximately 1% of cases. Nonsevere complica- palliation of malignant GOO has been a focus of debate. tions (eg, stent malfunction, pain, and occlusion of the In a systematic review, patients treated with enteral stents ampullary orifice leading to pancreatitis and/or cholangi- were more likely to tolerate oral intake (odds ratio 2.62; tis) are fairly common, occurring in approximately one 95% CI, 1.17-5.86; P ϭ .02) and to resume oral intake more fourth of cases.3,36,40 Stent malfunction caused by tumor quickly (mean difference 7 days) than patients treated with ingrowth, food impaction, or stent migration is the most gastrojejunostomy.58Furthermore, patients receiving en- commonly reported complication (17%) and is typically teral stents had a shorter hospital stay (mean difference 12 managed by insertion of additional stents and/or clearance days). There were no significant differences in mortality, of the food impaction. Stent migration within 8 weeks of complication rates, or overall survival. In a retrospective placement was significantly more common with covered study of 95 patients, those undergoing SEMS placement SEMSs (currently not available in the United States) com- had a more rapid development of late (Ͼ7 days) compli- pared with uncovered SEMSs (28% vs 3%; P ϭ .009).45 cations including recurrent obstructive symptoms and Repositioning or removal of distally migrated stents can be need for reintervention during 3 months of follow-up, attempted when recognized early.35,43 Placement of an indicating a more durable effect of gastrojejunostomy.59 additional SEMS is usually effective if repositioning fails. Three prospective, randomized studies comparing SEMS Completely migrated stents can cause intestinal obstruc- and surgery have been reported.47,60,61 One study has tion requiring surgical intervention.39,45 shown improvement in quality-of-life score with SEMS but

16 GASTROINTESTINAL ENDOSCOPY Volume 74, No. 1 : 2011 www.giejournal.org The role of endoscopy in gastroduodenal obstruction and gastroparesis none with surgical bypass,47 whereas another did not box warning from the U.S. Food and Drug Administration show a difference between the groups.61 All 3 studies recommending that its continuous use not exceed 3 showed comparable rates of technical success and mortal- months. The macrolide , including erythromy- ity, and longer hospital stay with surgery.47,60,61 SEMS cin, azithromycin, and clarithromycin, act as motilin- placement was associated with more rapid improvement receptor agonists to stimulate gastric motility. Although in symptoms.60,61 In the recent largest randomized study erythromycin is a potent stimulant of gastric emptying, with longer follow-up, late complications (ie, recurrent side effects are common with oral use (eg, nausea, vom- obstruction and need for reintervention) were more com- iting, abdominal cramping, ). Furthermore, tachy- mon with an SEMS than with gastrojejunostomy, confirm- phylaxis often will limit long-term efficacy. ing the results of the previous retrospective study suggest- Endoscopic therapies. When gastroduodenal dysmo- ing the benefit of surgical gastrojejunostomy in patients tility is associated with weight loss, recurrent episodes of with longer life expectancy.59,61 , or disturbances, supplemental nu- Multiple studies have compared the cost of endoscopic trition via enteral or parenteral routes should be consid- stenting with those of gastrojejunostomy for palliation and ered. In patients with isolated gastric dysmotility, postpy- have uniformly found that an endoscopic approach was loric enteral nutrition is preferable to TPN, given the costs 61-64 more cost-effective. A decision-analytic model com- and potential side effects (eg, infection, vascular thrombo- paring open gastrojejunostomy, laparoscopic gastrojeju- sis, ) associated with TPN. A detailed review nostomy, and endoscopic stenting for malignant gastrodu- of the treatment of gastroparesis, including timing and odenal obstruction showed that SEMS placement was the indications for enteral nutrition supplementations4 and a most cost-effective strategy and was associated with the guideline for the role of endoscopy in enteral feeding55 lowest rate of complications and the highest success rate have previously been published. PEG may also be used to 65 over a 1-month period. Therefore, although surgical pal- facilitate gastric decompression in selected individuals.68-71 liation offers more durable results than SEMS placement, Botulinum toxin is a neurotoxin that irreversibly binds SEMS placement would be a more appropriate option for to cholinergic receptors and impairs acetylcholine re- those patients with poor performance status and/or a short lease.72 Botulinum toxin has been evaluated for the treat- life expectancy. Ultimately, the palliative approach chosen ment of gastroparesis and is typically injected in a radial should depend on local expertise and the patient’s prog- pattern at or within 2 cm of the pylorus, with a total dose nosis and preferences. of 100 to 200 units. Numerous uncontrolled studies have shown symptom reduction in patients with gastroparesis Motility disorders treated with pyloric botulinum toxin injection.73-77 How- Medical therapies. Whenever possible, medications ever, 2 placebo-controlled trials involving a small number that delay gastric emptying or slow intestinal transit (eg, 76,78 narcotics, anticholinergics, calcium channel blockers) of patients (55 total) showed no significant benefit. If should be discontinued in patients with dysmotility of the there are benefits from endoscopic botulinum toxin injec- upper GI tract. Glycemic control should be optimized in tion, they may depend on the dose used and patient diabetic patients because hyperglycemia may delay gastric selection. In a retrospective cohort study of 179 patients, emptying and reduce antral contractility independent of doses of 200 units were beneficial in a significantly greater the presence or absence of diabetic neuropathy.66,67 Di- proportion of patients than doses of 100 units (77% vs ϭ 77 etary measures that may reduce symptoms include con- 54%, P .02). In this same study, multivariate analysis sumption of small, frequent meals that are low in fat and showed that female sex, age younger than 50 years, and low residue. In severe cases, ingestion of calories in a etiology other than diabetes or surgical vagal nerve ma- liquid rather than a solid form may be beneficial. Proki- nipulation were associated with an improved response to netic and medications may be used to increase therapy. The reported duration of benefit from pyloric gastric contractility, promote gastric emptying, and reduce botulinum toxin ranges from 1 to 5 months, and repeated symptoms overall. Metoclopramide and domperidone act injections may be associated with the return of clinical as dopamine receptor antagonists in the stomach to im- response in a subset of patients.77,79 prove gastric emptying and block emetic pathways in the In patients with gastroduodenal dysmotility and symp- brainstem. However, domperidone is not approved by the toms refractory to medical or botulinum toxin therapy, U.S. Food and Drug Administration and is only available in placement of decompressive gastrostomy can be effec- the United States as a compounded drug. Metoclopramide, tive.69,71 In a small (N ϭ 8) series of women with idiopathic unlike domperidone, crosses the blood-brain barrier re- gastroparesis, placement of a venting gastrostomy was sulting in side effects (eg, fatigue, drowsiness, irritability, associated with significant improvement in symptoms and acute dystonic reactions) that may limit clinical use. Infre- weight gain that was sustained at 3 years.69 There are no quently, metoclopramide may produce Parkinson-like published studies of endoscopic dilation of the pylorus symptoms or tardive dyskinesia that may not resolve with using balloons or bougienage dilators in patients with discontinuation of the medication and have led to a black- gastroparesis. www.giejournal.org Volume 74, No. 1 : 2011 GASTROINTESTINAL ENDOSCOPY 17 The role of endoscopy in gastroduodenal obstruction and gastroparesis

Gastric pacing. Gastric pacing using electrical stimu- though abdominal US or CT may be necessary for deter- lation delivered via electrodes implanted in the peritoneal mination of the source of obstruction before surgery. Hy- side of the anterior stomach wall has been used in the pertrophic is diagnosed as a palpable treatment of gastroparesis refractory to medical or endo- pyloric mass confirmed with transabdominal US or an scopic therapies. Leads are typically inserted surgically, upper GI contrast study.87 Endoscopy is not indicated in although there has been a reported case series (N ϭ 20) of the management of pyloric stenosis; however, high- temporary gastric pacing using an endoscopic tech- resolution EUS may be useful in imaging the pyloric mass nique.80 An open-label, multicenter study of 38 patients in equivocal cases,88 and pneumatic balloon dilation has showed a decrease in nausea and vomiting, as well as been used successfully in cases presenting outside of weight gain in 35 patients treated with gastric pacing,81 but infancy.89,90 sham stimulation–controlled studies have produced lesser It is important to note that obstructing lesions in the 81,82 clinical responses. Complications associated with gastric cavity, such as an antral web and a pedunculated these devices occur in as many as one fourth of patients mass, may be missed with contrast studies. Upper endos- and include infection, lead dislodgment, and wire break- copy is diagnostic in such cases and may also be thera- age. The relatively high rate of complications led the U.S. peutic (eg, in the setting of an antral web91). Endoscopy is Food and Drug Administration to limit the use of the also essential for the diagnosis of mucosal inflammation device to humanitarian indications and to centers in which causing pyloric obstruction, such as with eosinophilic gas- the local institutional review board has approved its use. tropathy.92 Although the paucity of data precludes any Contraindications to device placement include diffuse mo- specific recommendations regarding endoscopy in the tility disorders (eg, amyloidosis, scleroderma), previous management of GOO in children, it is advisable that chil- gastric resections, and the presence of other neurostimu- dren without a clear diagnosis despite radiologic investi- lating or pacing (including cardiac) devices. gation for GOO symptoms undergo a diagnostic endos- Surgical therapies. There are a variety of surgical copy to exclude structural abnormality. interventions that have been performed for the treatment Motility disorders have also been reported in children. of severe, refractory gastroparesis including pyloroplasty, Delayed gastric emptying is most commonly reported to complete or partial gastrectomy, or feeding jejunostomy, occur after viral infections, although it may also result from although there are no randomized trials.83 In a retrospec- eosinophilic gastropathy.93 Gastroparesis is not a signifi- tive study of 26 patients with diabetic gastroparesis who had undergone surgical jejunostomy placement, 83% re- cant feature in pediatric diabetic patients; however, idio- 94 ported improved overall health, although only 39% re- pathic functional GOO has been described in children. ported symptom improvement.84 In a large (N ϭ 81) ret- Endoscopy is indicated for children with evidence to sug- rospective study, 80% of patients with postsurgical gest gastric emptying delay, gastroparesis, or functional gastroparesis who had undergone near-total gastrec- GOO to examine for mucosal pathology. Although gas- tomy with Roux-en-Y reconstruction reported long-term troduodenal motility has been used to guide therapy in symptom relief.85 In contrast, a second study reported children with GI motility abnormalities, this procedure is symptom improvement in only 43% of 62 patients who still considered investigational and is not widely avail- 95 had undergone the same surgery for severe postva- able. Most medical and surgical options described in gotomy gastroparesis.86 adults for gastroparesis have also been used in children. For example, the management of idiopathic functional SPECIAL CONSIDERATIONS FOR THE GOO in children has involved gastric outlet surgery, and PEDIATRIC POPULATION pneumatic balloon dilation has also been described.96,97

GOO in early infancy often results from congenital Recommendations defects of the upper GI tract (Table 2). Hypertrophic py- loric stenosis, the most common cause of GOO in chil- 1. We recommend endoscopy for the evaluation of patients dren, typically presents in early infancy. Diagnosis is di- with suspected gastroduodenal obstruction. QQQQ rected by the clinical picture and radiologic evaluation. 2. We recommend SEMS placement for the treatment of Clinical features include those typical of upper intestinal malignant gastroduodenal obstruction in those patients obstruction (eg, vomiting), although a history of polyhy- with poor performance status and/or short life expec- dramnios during may signify the presence of in tancy. QQQŒ For other patients with malignant gas- utero obstruction before delivery. Plain abdominal x-rays troduodenal obstruction, surgical gastrojejunostomy may show the absence of gas beyond the stomach or the may offer a more durable result. The palliative ap- typical “double-bubble” of duodenal atresia; the second proach chosen should depend on local expertise and air fluid level is from a distended proximal and the patient’s prognosis and preferences. a markedly distended gastric cavity. An upper GI contrast 3. We recommend endoscopic biliary SEMS placement be- study is typically the next investigation performed, al- fore enteral SEMS placement for malignant gastroduode-

18 GASTROINTESTINAL ENDOSCOPY Volume 74, No. 1 : 2011 www.giejournal.org The role of endoscopy in gastroduodenal obstruction and gastroparesis

nal obstruction in the setting of established or impending 8. Tada S, Iida M, Yao T, et al. Intestinal pseudo-obstruction in patients with biliary obstruction, when technically possible. QQQŒ amyloidosis: clinicopathologic differences between chemical types of 4. We suggest palliative decompressive gastrostomy when amyloid protein. Gut 1993;34:1412-7. 9. Soykan I, Sivri B, Sarosiek I, et al. Demography, clinical characteristics, malignant gastroduodenal obstruction is not amenable psychological and abuse profiles, treatment, and long-term follow-up to surgical bypass or SEMS placement. QQŒŒ of patients with gastroparesis. Dig Dis Sci 1998;43:2398-404. 5. We suggest endoscopic balloon dilation for the man- 10. Parkman HP, Schwartz SS. and gastroduodenal disorders asso- agement of benign GOO. QQŒŒ ciated with diabetic gastroparesis. Arch Intern Med 1987;147:1477-80. 6. We recommend optimization of medical and dietary 11. Helyer L, Easson AM. Surgical approaches to malignant bowel obstruc- tion. J Support Oncol 2008;6:105-13. measures (eg, improved glycemic control) before en- 12. Maglinte DD, Howard TJ, Lillemoe KD, et al. Small-: doscopic interventions for the management of gas- state-of-the-art imaging and its role in clinical management. Clin Gas- troduodenal dysmotility. QQQŒ troenterol Hepatol 2008;6:130-9. 7. We recommend enteral nutrition for severe and refrac- 13. Jaffer U. Towards evidence based emergency medicine: best BETs from tory gastroparesis because it is associated with fewer the Manchester Royal Infirmary. Computed tomography for small complications and lower cost compared with paren- bowel obstruction. Emerg Med J 2007;24:790-1. QQQŒ 14. Desser TS, Gross M. Multidetector row computed tomography of small teral nutrition. bowel obstruction. Semin CT MR 2008;29:308-21. 8. There are insufficient data to make a recommendation 15. Morcos SK. Review article: Effects of radiographic contrast media on the regarding the role of botulinum toxin in the treatment lung. Br J Radiol 2003;76:290-5. of gastroparesis. 16. Parkman HP, Hasler WL, Fisher RS. American Gastroenterological Asso- 9. We recommend endoscopy for the evaluation of infants ciation technical review on the diagnosis and treatment of gastropare- sis. 2004;127:1592-622. and children with suspected gastroduodenal obstruction 17. Wiley JW, Nostrant TT, Owyang C. Evaluation of gastrointestinal motility: when radiologic studies are inconclusive or unrevealing methodologic considerations, 3rd ed, vol 2. Malden (Mass): Wiley-Blackwell; or when endoscopic therapy is indicated. QQŒŒ 1999. 18. Greydanus MP, Camilleri M. Abnormal postcibal antral and small bowel motility due to neuropathy or myopathy in systemic sclerosis. Gastro- enterology 1989;96:110-5. DISCLOSURE 19. Camilleri M, Malagelada JR. Abnormal intestinal motility in diabetics with the gastroparesis syndrome. Eur J Clin Invest 1984;14:420-7. Dr Harrison served as a consultant for Fujinon, Inc. Dr 20. Cassilly D, Kantor S, Knight LC, et al. Gastric emptying of a non-digestible Decker served as a consultant for Facet Biotechnology. Dr solid: assessment with simultaneous SmartPill pH and pressure capsule, Fanelli received honoraria from Ethicon, served as a con- antroduodenal manometry, gastric emptying scintigraphy. Neurogas- sultant for RII Biologics, and is the owner/governor of New troenterol Motil 2008;20:311-9. 21. Kloetzer L, Chey WD, McCallum RW, et al. Motility of the antroduode- Wave Surgical Corp. Dr Jain served as a researcher for num in healthy and gastroparetics characterized by wireless motility BARRX Medical, Inc. No other financial relationships rel- capsule. Neurogastroenterol Motil 2010;22:527-33, e117. evant to this publication were disclosed. 22. Szarka LA, Camilleri M. Methods for measurement of gastric motility. Am J Physiol Gastrointest Liver Physiol 2009;296:G461-75. 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76. Arts J, van Gool S, Caenepeel P, et al. Influence of intrapyloric botulinum 92. Kellermayer R, Tatevian N, Klish W, et al. Steroid responsive eosinophilic toxin injection on gastric emptying and meal-related symptoms in gas- gastric outlet obstruction in a child. World J Gastroenterol 2008;14: troparesis patients. Aliment Pharmacol Ther 2006;24:661-7. 2270-1. 77. Coleski R, Anderson MA, Hasler WL. Factors associated with symptom 93. Gariepy CE, Mousa H. Clinical management of motility disorders in chil- response to pyloric injection of botulinum toxin in a large series of gas- dren. Semin Pediatr Surg 2009;18:224-38. troparesis patients. Dig Dis Sci. Epub 2009 Jan 30. 94. Sharma KK, Ranka P, Goyal P, et al. Gastric outlet obstruction in children: 78. Friedenberg FK, Palit A, Parkman HP, et al. Botulinum toxin A for the an overview with report of Jodhpur disease and Sharma’s classification. treatment of delayed gastric emptying. Am J Gastroenterol 2008;103: J Pediatr Surg 2008;43:1891-7. 416-23. 95. Cucchiara S, Minella R, Scoppa A, et al. Antroduodenal motor effects of 79. Bromer MQ, Friedenberg F, Miller LS, et al. Endoscopic pyloric injection intravenous erythromycin in children with abnormalities of gastrointes- of botulinum toxin A for the treatment of refractory gastroparesis. Gas- tinal motility. J Pediatr Gastroenterol Nutr 1997;24:411-8. trointest Endosc 2005;61:833-9. 96. Jawaid W, Abdalwahab A, Blair G, et al. Outcomes of pyloroplasty and 80. Ayinala S, Batista O, Goyal A, et al. Temporary gastric electrical stimula- pyloric dilatation in children diagnosed with nonobstructive delayed tion with orally or PEG-placed electrodes in patients with drug refrac- gastric emptying. J Pediatr Surg 2006;41:2059-61. tory gastroparesis. Gastrointest Endosc 2005;61:455-61. 97. Israel DM, Mahdi G, Hassall E. Pyloric balloon dilation for delayed gastric 81. Abell TL, Van Cutsem E, Abrahamsson H, et al. Gastric electrical stimulation emptying in children. Can J Gastroenterol 2001;15:723-7. in intractable symptomatic gastroparesis. 2002;66:204-12. 82. Abell T, McCallum R, Hocking M, et al. Gastric electrical stimulation for medically refractory gastroparesis. Gastroenterology 2003;125:421-8. 83. Jones MP, Maganti K. A systematic review of surgical therapy for gastro- paresis. Am J Gastroenterol 2003;98:2122-9. 84. Fontana RJ, Barnett JL. Jejunostomy tube placement in refractory dia- Prepared by: betic gastroparesis: a retrospective review. Am J Gastroenterol 1996;91: ASGE STANDARDS OF PRACTICE COMMITTEE 2174-8. Norio Fukami, MD 85. Eckhauser FE, Conrad M, Knol JA, et al. Safety and long-term durability of Michelle A. Anderson, MD completion gastrectomy in 81 patients with postsurgical gastroparesis Khalid Khan, MD, NASPGHAN Representative syndrome. Am Surg 1998;64:711-6; discussion 716-7. M. Edwyn Harrison, MD 86. Forstner-Barthell AW, Murr MM, Nitecki S, et al. Near-total completion Vasudhara Appalaneni, MD gastrectomy for severe postvagotomy gastric stasis: analysis of early Tamir Ben-Menachem, MD and long-term results in 62 patients. J Gastrointest Surg 1999;3:15-21; G. Anton Decker, MD discussion 21-3. Robert D. Fanelli, MD, SAGES Representative 87. Hernanz-Schulman M. Pyloric stenosis: role of imaging. Pediatr Radiol Laurel Fisher, MD 2009;39(Suppl 2):S134-9. Steven O. Ikenberry, MD 88. Khan K. High-resolution EUS to differentiate hypertrophic pyloric steno- Rajeev Jain, MD sis. Gastrointest Endosc 2008;67:375-6. Terry L. Jue, MD 89. Nasr A, Ein SH, Connolly B. Recurrent pyloric stenosis: to dilate or oper- Mary Lee Krinsky, DO ate? A preliminary report. J Pediatr Surg 2008;43:e17-20. John T. Maple, DO 90. Lin JY, Lee ZF, Yen YC, et al. Pneumatic dilation in treatment of late- Ravi N. Sharaf, MD onset primary gastric outlet obstruction in childhood. J Pediatr Surg Jason A. Dominitz, MD, MHS, Chair 2007;42:e1-4. This document is a product of the ASGE Technology Assessment Commit- 91. Maldonado ME, Mamel JJ, Johnson MC. Resolution of symptomatic tee. This document was reviewed and approved by the Governing Board of GERD and delayed gastric emptying after endoscopic ablation of antral the American Society for Gastrointestinal Endoscopy. diaphragm (web). Gastrointest Endosc 1998;48:428-9.

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